Hematocolpos on late-onset hymenal
imperforation: A case report
IMAGING
CASE REPORT
IMAGING (2022)
DOI: 10.1556/1647.2022.00069
© 2022 The Author(s)
p
Corresponding author.
Tel.: þ212 638864103.
E-mail: diarradaoud12@gmail.com
DAOUDA DIARRA1p , ABDOULFATIHI SALIHOU1,
BOUBACAR TRAORE2 , DALALE LAOUDIHI1,
KAMILIA CHBANI1, SIHAM SALAM1 and
LAHCEN EL OUZIDANE1
1
Department of Pediatric Radiology, CHU Ibn Rochd, Faculty of Medicine and Pharmacy of
Casablanca, Hassan II University, Morocco
2
Epidemiology Laboratory, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University,
Morocco
Received: January 3, 2022 • Accepted: March 29, 2022
ABSTRACT
We report the case of a patient with hematocolpos on hymenal imperforation, revealed following
cyclic pelvic pain with primary amenorrhea associated with pelvic heaviness for one year. MRI showed
significant distension of the vagina forming a pseudo mass, well limited, in T1 high signal, in moderate
T2 high signal, with the presence of declining deposits in hyposignal related to hemosiderin. A
hymenotomy was performed under general anaesthesia, the postoperative course was favourable.
This case illustrates the particularity of suspecting a hematocolpos in the presence of a pelvic mass in a
young girl with amenorrhea.
KEYWORDS
hematocolpos, hymenal imperforation, amenorrhea, ultrasound, MRI
Introduction
Hymen imperforation, vaginal atresia, and transverse vaginal septum have been documented as
the major causes of congenital vaginal obstruction. Hematocolpos is a progressive accumula-
tion of menstrual blood in the vaginal cavity. It is mainly caused by hymenal imperforation [1].
Hymenal imperforation is rarely diagnosed during the neonatal period and usually pre-
sents later in puberty as cyclic pelvic pain, primary amenorrhea or a pelvic mass. The
diagnosis of hymenal imperforation can be made by gynecological examination. Ultrasound
is decisive for the diagnosis of hématocolpos [2].
MRI is used to confirm the diagnosis and to assess the extent of the disease in search of
any associated urogenital malformations [3].
The literature cites rare cases of imperforate hymen with a hematocolpos diagnosed on
ultrasound and MRI.
Our case illustrates a hematocolpos secondary to hymenal imperforation diagnosed in a
young girl with primary amenorrhea and a pelvic mass.
Observation
This was a 17-year-old girl referred to the gynecology consultation for cyclic pelvic pain with
primary amenorrhea associated with pelvic heaviness for one year.
On clinical examination, she had no fever and her blood pressure was normal. A pelvic
tuck with a median mass reaching above the umbilicus, tender, firm and mobile was found on
abdominal examination. This mass was suspected to be of tumoral origin.
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2 Hematocolpos on late-onset hymenal imperforation IMAGING

Fig. 1. MRI of the pelvis: Hematocolpos in axial sequence T1 (A), Sagittal sequence T2 (B) and Axial sequence T2 (C). Legends: Star: cervix
of the uterus, Red arrow: hematocolpos pushing up the uterus on the sagittal section, Blue arrow: bladder

Fig. 2. MRI of the pelvis: Hematocolpos in Axial sequence Diffusion (A) and Axial sequence ADC mapping (B). Legends: Red arrow:
hematocolpos pushing up the uterus on the sagittal section, Blue arrow: bladder

The biological tests (blood and urine) were normal.
A suprapubic ultrasound revealed a median, hypoechoic,
retrovesical fluid formation with a fine echogenic content.
This collection was surmounted by the undistended
communicating uterine cavity.
The MRI showed a significant distension of the vagina
forming a pseudo mass, well limited, in T1 high signal
(Fig. 1A), in moderate T2 high signal (Fig. 1B), with the
presence of declining deposits in hyposignal related to he-
mosiderin (Fig. 1C). This formation is in diffusion high
signal (Fig. 2A) with intermediate ADC (Fig. 2B). It mea-
sures 939 cm extended by 22 cm in height and displaces the
uterus upward. The uterus was of normal size, with regular
contours and a small endo uterine retention, without
obvious uterine distension.
The bladder was pushed forward in semi-repletion with
thin walls and homogeneous contents; the rectum and sig-
moid colon were pushed backward. A fluid effusion blade
was at the level of the left iliac fossa.
No other utero-annexal abnormalities were found.
The diagnosis of hematocolpos was evoked. The patient
was re-examined and the examination of the external geni-
talia showed an imperforate and bulging hymen. The
diagnosis retained was hematocolpos on imperforate hymen.
A hymenotomy was performed under general anesthesia,
approximately 1 L 400cc was collected and the patient
recovered without complications.
Discussion
Hematocolpos is the vaginal retention of menstruation. It is
formed at puberty from the first menstruation, and hymenal
perforation is the most common etiology. A higher situated
complete vaginal diaphragm, or partial vaginal atresia are
rarer causes [4]. The prevalence of hymenal imperforation is
0.1% [4] and its familial nature is exceptional [5]. Puberty is
the most propitious time for discovery of hematocolpos
secondary to hymen imperforation.
The hymenal imperforation could be due to a defect in
apoptosis or an inappropriate hormonal environment [1].
Secondary sexual characteristics are present and coexist with
primary amenorrhea.
The typical clinical picture is dominated by the presence
of cyclic median pelvic pain that may sometimes take on a
pseudo-appendicular character, sometimes accompanied by

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IMAGING
lumbosciatica [5]. A pelvic mass syndrome may, in case of
voluminous hematoma, cause urological and/or digestive
complications such as urinary retention, dysuria, hydro-
nephrosis or constipation [6].
The consequences of hematocolpos on fertility through
the risk of endometriosis or infection are not to be neglected.
The diagnosis is easy to establish clinically and is made
during gynecological examinations. In gynecological exam-
inations, an obstruction of the vaginal orifice by an intact,
thin, semi-transparent, bulging membrane (hymen) is
observed in a patient who has not yet menstruated despite
the development of secondary sexual characteristics [4, 6].
Imaging examinations play an important role in the
differential diagnosis in case of suspicion of other etiologies.
Indeed, a fine echogenic retro bladder image, sur-
mounted by a small, dilated, communicating uterine cavity
with a fluid content in case of hematometra may be observed
on suprapubic ultrasound [7]. A hematosalpinx or perito-
neal effusion may also be seen [5]. Uterine malformations
and renal agenesis in cases of genital duplication are sys-
tematically sought [4]. Rarely, Herlyn Werner Wunderlich
syndrome with a blind hemivagina, uterine duplication and
unilateral renal agenesis is distinguished [2]. Ultrasound
may also show ureteropyelocal dilatation in case of
compression of the urinary tracts by the hematoscope [8].
Like ultrasonography, MRI has the benefit of innocu-
ousness in a young girl. It would therefore be the best
complementary exploration technique giving on T2-
weighted sequences a very good anatomical morphological
analysis of the malformation. Confirmation of the hematic
content in the vagina and in the overlying uterine horn [3, 7]
will be evidenced by the T1-weighted sequences.
The treatment of hymenal imperforation is, above all,
surgical. It consists of a hymenotomy. Its aim is to drain the
hematocolpos and restore vaginal flow. Several incisions have
been described: vertical, T-shaped, cross, radial and circum-
ferential incisions [9]. Circumferential incisions should be
avoided because they lead to orifice stenosis, a source of dys-
pareunia. The hymenotomy must meet two requirements: to
respect the orifices of Bartholin’s glands and to encourage
urethro-hymenal disassociation. In addition, it is recom-
mended not to exert pressure on the uterus during emptying so
as not to encourage tube reflux responsible for pelvic endo-
metriosis. A post-menstrual consultation is envisaged to ensure
that there is no stenosis and to confirm hymenal healing [10].
Conclusion
Hematocolpos is a more or less complex genital anomaly, and
the mode of revelation varies according to the age group.
Imaging allows to orientate the diagnosis, to look for
possible associated urogenital malformations and signs of
compression, especially urinary. MRI is particularly useful in
the study of complex malformations.
Open Access. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (https://
creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the
original author and source are credited, a link to the CC License is provided, and changes – if any – are indicated.
Daouda Diarra et al. 3
Therapeutic management must be early to avoid com-
plications which can be sometimes lethal.
Funding sources: No financial support was received for this
case report.
Authors’ contribution: Author’s contribution: All persons who
meet authorship criteria are listed as authors, and all authors
certify that they have participated sufficiently in the work to
take public responsibility for the content, including partici-
pation in the concept, writing, or revision of the manuscript.
Acquisition of images: DD, SA. Interpretation of literature:
DD, SA. Drafting the manuscript: DD, SA, BT. Revising the
manuscript critically for important intellectual content: BT,
LD, CK, SS and EL. Approval of the version of the manuscript
to be published: DD, SA, BT, LD, CK, SS and EL.
Conflict of interest: The authors declare no conflict of interest.
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